Would a vaccination policy work to control the current cholera outbreak in Yemen?

Last week’s statistics on the cholera epidemic in Yemen, currently the largest in the world, included an incidence of half a million people in 2017, with 2000 deaths since April (http://www.who.int/mediacentre/news/releases/2017/ cholera-yemen-mark/en). Having appeared to successfully contain a first surge in incidence between October 2016 and April 2017, international health organizations in the area saw a much more sudden, drastic increase in the number of individuals affected in May 2017, primarily thought to be due still to the breakdown in the provision of adequate water, sanitation and nutrition as the war that started 2 years ago continues to rage on.

Facilities, workers and supplies that are much needed to provide emergency and primary health services face increasingly greater shortages, having been early victims of the collapsed governmental infrastructure and resources, and because of having been targeted specifically by the fighting forces (less than half of facilities are still fully functional; see photo at http://www.ibtimes.co.uk/civil-war-yemen-two-years-horrifying-conflict-75-powerful-photos-1605848#slideshow/1590015).

Although vaccines, antibiotics and the provision of basic health services would help prevent and control the outbreak, the multiple inter-related factors of population displacement, targeting of health facilities and access points for incoming medical supplies, famine, ongoing war conditions, all in the context of pre-existing poverty, famine, and poor national, state and local health infrastructure and resources, make a reversal of these conditions nearly impossible (https://www-clinicalkey-com.ezp.welch.jhmi.edu/#!/content/journal/1-s2.0-S1473309917304061).

I have been struggling to arrive at a solution – which brings me to this blog; I want to ask anyone out there, with more experience, and perhaps more faith than I have – wherein lies the answer? Individuals, families, friends, communities in this case – have little to no control over their fate; they are fighting against extinction; national healthcare organizations have little remaining resources, and are caught in the midst of the fight between the Saudi-backed President Hadi and the Houthi insurgents. Any positive changes would have to come, as far as I see it, from international health aid organizations such as the WHO, MSF, IRC, and UN-led advocacy for cessation of war.

Policies enabling better distribution and administration of the cholera vaccine and oral rehydration solutions are futile – there is no viable national, state or local infrastructure in place to implement any such policies. How does one defend such policies against the prevailing forces which oppose them, whose interests lie only with the retention of / ascension to political power, and little with the survival of the population at large? (see photo at http://www.who.int/emergencies/yemen/en/)

And yet, vaccine distribution campaigns had been considered (http://www.sciencemag.org /news/2017/06/cholera-vaccine-faces-major-test-war-torn-yemen) and were being planned for, as of June 2017; the government had asked for 3.5 million doses (single dose regimen), yet had given no guarantee that it would reach its intended population, that there’d be health workers to deliver it, or safe locations for such a delivery of vaccines as well as basic health care. In fact, the rampant spread of the disease led the UN to suspend its plan just one month later.

A discussion held (https://www.brookings.edu/wp-content/uploads/2016/02/yemen-transcript.pdf) in Qatar last year by a panel of international experts revolved around economic policies aimed at reviving the economy (even a “war” economy would help dispel the sense of individual futility), depoliticizing of the food and medical aid supplies brought in by international organizations through local ports, de-legitimizing the Houthis and acknowledging them as leaders of a coup d’etat instead, and ultimately preventing them from acquiring weapons. These appear viable alternatives in a country where a ceasefire is nowhere near in sight, and the rebuilding of the much needed health infrastructure would take many years and resources, thus rendering the term “policy” at the local and national level meaningless, for the time being.

2 Responses to “Would a vaccination policy work to control the current cholera outbreak in Yemen?”

Good afternoon. What a giant problem and issue! You gave much good evidence to describe the magnitude of the cholera problem within Yemen currently, and how the physical and political environment is a huge impediment to access and availability of health products and services for people. The key indicators are death and illness, and these are rising rates. Thank you for asking for solutions and sharing how the availability of vaccines cannot, in isolation, begin to address all the root causes for the problem of cholera. It prompted for me, a conversation with my Infectious Disease Specialist father, who served in the Navy during the Viet Nam war and provided medical services during malaria and cholera efforts in Pakistan. He later worked with the CDC cholera surveillance team in Pakistan too. When I read him this post, he suggested the most basic and essential intervention should be the provision of bottled water. The problems with access that vaccines face will also be experienced with a water solution; however, without water, no solution is sustainable. Rather than spend resources on vaccines that might not end up being used for their intention, an investment in water should be made. If resources allow for vaccines after water, then this should happen. But if clean water is not present, cholera will spread, and no vaccine campaign will succeed. Cold, hard truth. Yemen is lucky to have you working and thinking about this problem and I advise to narrow the scope to one root cause that would be least argued against and most feasible. Good luck and I will also pray for Yemen.

Great post! I agree with marikahre – what a huge problem facing the world today, and what a great recommendation (what a nice resource you have!).

I have been trying to follow the status of Yemen in the news. This epidemic is so unfortunate because cholera “should be” preventable! When I first read that the UN were not sending the vaccines to Yemen, I was at first confused – how can you not help them when they are down? As I read more I understood the predicament of the situation better, still it is tough to imagine. Such a heartbreaking situation at that, when vaccines, the seemingly simplest form of prevention is not feasible.

I hope this epidemic will help prepare the global health organizations for future epidemics in war torn or disaster hit countries. When I think of other prevention measures, as an engineer, I think of prevention based remedies, but I can’t imagine campaigns in the middle of hostility would work well. Besides water, would it be more feasible to transport water purification tablets? like http://www.aquatabs.com/home/ ? I’m assuming access to water might be an issue though too.

Thank you for bringing this issue to my attention once again – I appreciate looking through a new lens to analyze problems.